Compositions Comprising Nicotinic Agonists and Methods of Using Same

ABSTRACT

The disclosure is directed at least in part to compositions and methods comprising nicotinic agonists for treating e.g., nervous system disorders, in particular, to combination therapies that include a nicotinic agonist (for example, nicotine) and a nicotinic acetylcholine receptor desensitization inhibitor (for example, opipramol).

RELATED APPLICATIONS

This application claims the benefit of U.S. Provisional PatentApplication Ser. No. 60/990,161 filed Nov. 26, 2007, the entiredisclosure of which is incorporated by reference herein.

FIELD

The present invention relates generally to compositions and methods oftreating and/or controlling a disease, disorder or addiction responsiveto the administration of a nicotinic agonist. At least in part, theinvention relates, to compositions that include a nicotinic agonist anda nicotinic acetylcholine receptors (nAChRs) desensitization inhibitor.

BACKGROUND

Nicotinic ACh receptors (nAChRs) comprise a class of pentameric(containing five subunits) ligand-gated ion channels present in thecentral (CNS) and the peripheral (PNS) nervous systems as well as in thestriated muscle. The nAChR of the nervous system and those found inperipheral neurons differ in structural (subunits composition) andfunctional aspects from nAChR found in striated muscles. Whereas thestriated muscle receptors contain 2 α subunits (α1) and one β (β1), oneγ and one δ (or one ε) subunits, the neuronal nAChR is composed of onlyα (at least two subunits among the α2 to α10 subtypes) and β (generallythree subunits among the β 2 to β 4 subtypes). The amino acid sequencefor the α subunits of the neuronal nAChR (α2 to α10) consists of aglycolipid region (which contains the ACh binding site and fourhydrophobic regions that span the membrane. The neuronal β subunits (β 2to β 4) do not have an adjacent pair of cystines, which are present inthe α subunit ligand-binding region.

In general terms, two molecules of ACh binds to each of the α-subunitsof the receptor and induce a conformational change in all the receptorsubunits, resulting in an opening of Na⁺/K⁺ channel, causing a localdepolarization. The local depolarization may develop to an actionpotential, leading to physiological response such as muscle contractionwhen summed with the action of several receptors in the neuromuscularjunction. Nicotinic receptors possess a relatively low affinity for AChat rest. The affinity for acetylcholine is increased after the bindingof the first ACh molecule (through an allosteric mechanism, whichincreases the likelihood of another molecule of ACh binding to the otherα subunit). After prolonged exposure to ACh and at e.g., highconcentrations of this neurotransmitter, the receptor channel may beclosed in spite of an e.g., increase affinity of ACh to the receptor andthe receptor subsequently can become desensitized.

An allosteric transition state model of the nAChR involves at least aresting state, an activated state and a “desensitized” closed channelstate. Different nAChR ligands can differentially stabilize theconformational state to which they preferentially bind. For example, theagonists ACh and (−)-nicotine stabilize first the active state and thenthe desensitized state.

The nAChR is involved in the regulation of a variety of brain functionssuch as thermoregulation, cognition, attention etc. Thus, potentially,treatment with nicotine or drugs that directly or indirectly activatethe nAChR may provide beneficial effects in alleviating cognitivedysfunctions such as dementia of Alzheimer's type, cognitive impairmentassociated with schizophrenia, attention deficit, e.g., in attentiondeficit hyperactivity disorder (ADHD). Nicotine has also been shown tobe neuroprotective and a negative correlation between smoking and thedevelopment of neurodegenerative disorders such as Parkinson's diseaseand Alzheimer's disease has also been reported. In addition, nicotine isalso used in cessation of smoking.

Over the past several years, a variety of research groups have focusedon the development of selective nicotinic agonists. Nicotinic agonistsmay be useful in the treatment of a variety of neurological disordersincluding Alzheimer's disease, Parkinson's disease, and chronic pain.For example, nicotinic agonists such as epibatidine, epiboxidine,ABT-418, ABT-594, and SIB-1508 (altinicline) have been shown to exhibitanalgesic properties suggesting that nAChR may be used as targets fornovel analgesics.

The rapid desensitization of the nAChR may make nicotine, and otheragents that activate directly or indirectly the nicotinic receptors,ineffective as therapeutic drugs. In addition, nicotinic agonists may beineffective due to a process of uncompetitive blockade (open-channelblock). Furthermore, prolonged activation appears to induce along-lasting receptor inactivation. It would be desirable to find drugsthat would retard desensitization of the receptor, thus prolonging thepositive effect of nicotinic agonists or making them more effectiveduring repeated administration.

SUMMARY

The present invention relates, in one aspect, to a pharmaceuticalcomposition comprising a nicotinic agonist and a nAChR desensitizationinhibitor, and a pharmaceutically acceptable carrier.

Any nicotinic agonist can be used in the compositions of the invention,such as, but not limited to, nicotine, nicotine metabolites,decamethonium bromide, epibatidine, lobeline, varenicline, epiboxidine,epiquinamide; ABT 418, i.e., (S)-3-methyl-5-(1-methyl-2-pyrrolidinyl)isoxazole, an isoxazole analog of (−)-nicotine that is an α4β2 nAChRagonist; ABT-594, an azetidine derivative of epibatidine; ABT-894;DMXB-A, i.e., 3-(2,4-dimethoxybenzylidene)-anabaseine (also known asGTS-21), an α7-nAChR selective agonist; SIB-1508 (altinicline); and RJR2403 (metanicotine), and pharmaceutically acceptable salts and isomersthereof. Examples of active nicotine metabolites contemplated by theinvention include cotinine, nornicotine, norcotinine, nicotine N-oxide,cotinine N-oxide, 3-hydroxy-cotinine, 5-hydroxy-cotinine andpharmaceutically acceptable salts thereof. Examples of nicotine saltsinclude nicotine citrate and nicotine maleate. In a preferredembodiment, the nicotinic agonist is nicotine or a pharmaceuticallyacceptable salt or N-oxide thereof.

Exemplary nAChR desensitization inhibitors that can be used in thecompositions of the invention include, but are not limited to, ionchannel inhibitors, sodium channel inhibitors, potassium channelinhibitors, calcium channel inhibitors, beta blockers, sigma receptorantagonists, norepinephrine (NE) reuptake inhibitors, selectiveserotonin reuptake inhibitors, muscarinic agonists, adenosineantagonists, kappa-opioid agonists, dopamine and/or serotonin receptorantagonists, neurosteroids, sigma 1 receptor agonists, and acetylcholineesterase inhibitors.

Examples of ion channel inhibitors include lidocaine and mepivacaine; ofsodium channel inhibitors include phenyloin, carbamazepine, lamotrigine,quinidine, procainamide, disopyramide, mexiletine, tocamide, flecamide,propafenone; of potassium channel inhibitors include nibetan, sotalol,amiodaraone, bretylium; of calcium channel inhibitors include verapamil,diltiazem; of beta blockers include propranolol, timolol, atenolol,metoprolol; of sigma receptor antagonists include opipramol, rimcazole;of NE reuptake inhibitors include dosulepin, lofepramine, nortriptyline,protriptyline; of selective serotonin reuptake inhibitors includeclomipramine; of muscarinic agonists include McN-A-343, arecoline,cevimeline (AF-102B), AF-150, and AF-267B; of adenosine antagonistsinclude caffeine; of kappa-opioid agonists include codeine orpentazocine; of dopamine and/or serotonin receptor antagonists includeclozapine, DHA, or quetipine; of neurosteroids include alphaxolone,minaxolone; of sigma 1 receptor agonists include pentazocine). Inpreferred embodiments, the nAChR desensitization inhibitor may beselected from opipramol, McN-A-343, galantamine, lidocaine andclomipramine, or a pharmaceutically acceptable salts, ester or prodrugthereof. Other nAChR desensitization inhibitors may include trazodone,norfluoxetine, fluoxetine, or zimelidine.

In some embodiments, the pharmaceutical composition may include anicotinic agonist and a nAChR desensitization inhibitor in a weightratio of nicotinic agonist:nAChR desensitization inhibitor of about 1:2to about 1:100, or about 1:5 to about 1:20, e.g. about 1:14.

Contemplated compositions of the invention may further comprise apharmaceutically acceptable carrier. In an embodiment, thepharmaceutically acceptable carrier is suitable for transdermal ortopical administration.

In preferred embodiments, the nicotinic agonist is nicotine, an isomer,pharmaceutically acceptable salt or N-oxide thereof, and the nAChRdesensitization inhibitor is opipramol, McN-A-343, lidocaine,galantamine or clomipramine, or a pharmaceutically acceptable salt orprodrug thereof. In a more preferred embodiment, a pharmaceuticalcomposition is provided that comprises: a) nicotine or apharmaceutically acceptable salt or N-oxide thereof, and b) opipramol ora pharmaceutically acceptable salt, ester, or prodrug thereof.

Contemplated compositions of the invention may be suitable for any oneof: oral, parenteral, transcutaneous, mucosal, transdermal or inhalationadministration, and may be in the form of a chewing gum, sachet, thinfilm, transdermal patch, capsule, tablet, or nasal spray.

For example, provided herein is a transdermal patch comprising thecomposition comprising nicotine, opipramol and a pharmaceuticallyacceptable carrier suitable for transdermal or topical administration,wherein said carrier may comprise a skin penetration enhancer. Such atransdermal patch may be formulated to provide substantially continuousdelivery of the nicotine and the opipramol to a patient.

Also provided herein is a controlled release composition for delivery ofa composition comprising nicotine, opipramol and a pharmaceuticallyacceptable carrier which is capable of delivering the composition in apre-determined delivery rate to a patient, for example wherein thepre-determined delivery rate is substantially continuously over at least12 hours, or over at least 1 day, or over at least 3 days, or over atleast 7 days (one week).

The pharmaceutical composition of the invention is useful for preventionor reduction of the transition of the nAChR to a “desensitized” closedchannel state normally occurring after prolonged exposure to e.g., anicotinic agonist. The compositions are useful for treatment of nervoussystem disorder, disease or condition such as CNS and PNS disorder,disease or condition. On one embodiment, the compositions are useful fortreatment of cognitive dysfunction or cognitive disorders. In some otherembodiments, the compositions are useful for treatment of CNS disordersincluding, but not limited to, anxiety, depression, Alzheimer's disease,Parkinson's disease, schizophrenia, attention deficit hyperactivitydisorder (ADHD), attention deficit disorder (ADD), vascular dementia,Lewy body disease, post-traumatic dementia, Pick's disease, multiplesclerosis, Jakob-Creutzfeldt disease, drug addition such as nicotineaddiction, alcohol addiction, cannabis addiction and cocaine addiction,obsessive disorders, compulsive disorders, impulse-control disorders,neurological conditions associated with acquired immune deficiencysyndrome (AIDS), analegesia, and Huntington's disease In some otherembodiments, the compositions are useful for treatment of PNS disordersincluding, but not limited to, neuropathies including mononeuropathiesand polyneuropathies such as carpal tunnel syndrome, Guillain-Barresyndrome, facial palsy (or Bell's palsy), neuropathies caused byinfectious agents, or diabetic, amyloid, and/or brachial plexusneuropathies,

In one preferred embodiment, the composition of the invention is usefulfor treating or suppressing tobacco or nicotine dependence or usage,thus inducing smoking cessation.

Administration of a composition of the invention may provide for aneffect of a subsequent administration of the nicotinic agonist to apatient that is substantially more therapeutically effective as comparedto a subsequent administration of a nicotinic agonist using a method fortreatment consisting of administering a nicotinic agonist alone.Additionally or separately, the disclosed compositions may provide foran effect of the nicotinic agonist that is substantially prolongedfollowing said co-administration of the nAChR desensitization inhibitoras compared to administering to a patient a nicotinic agonist alone. Forexample, the effect of nicotinic agonist after co-administration ofnAChR desensitization inhibitor may be about twice as effective ascompared to administering to the patient the nicotinic agonist alone. Insome embodiments, the nAChR desensitization inhibitor may reduce thedesensitization of said nicotinic agonist for at least about 3 hours, atleast about 12 hours, or at least about 1 day, at least about 3 days ormore.

The nicotinic agonist and the nAChR desensitization inhibitor may beadministered together in the same dosage form, or in separate dosageforms, e.g. different dosage forms. In some embodiments, the nicotinicagonist and the nAChR desensitization inhibitor may be administeredsequentially or may be administered successively separated by about 10minutes to about 4 hours, or about 10 minutes to about 12 hours, or 10minutes to about 24 hours or more. Contemplated herein are embodimentswherein the nicotinic agonist and the nAChR desensitization inhibitorare each administered via a formulation chosen from: oral, parenteral,mucosal, inhalation and transdermal formulations, or a combinationthereof, for example, the nicotinic agonist and the nAChRdesensitization inhibitor may be co-administered in the form of chewinggum, sachets, thin film, transdermal patches, capsules, tablets,lozenges, or nasal sprays. For example, the nicotinic agonist may beadministered transdermally, and the nAChR desensitization inhibitor maybe administered orally or may be administered transdermally.

In some embodiments, the contemplated compositions include the nicotinicagonist and the nAChR desensitization inhibitor each administered in asubstantially continuous manner over at least 12 hours, or over at least1 day, or over at least three days, or over at least one week. Forexample, in one embodiment, the nicotinic agonist and the nAChRdesensitization inhibitor may be administered in one transdermal patch.In another embodiment, the nicotinic agonist is delivered in a firsttransdermal patch and the nAChR desensitization inhibitor isadministered in a second transdermal patch.

In accordance with the invention, the administration of the nicotinicagonist and the nAChR desensitization inhibitor may be repeated severaltimes, e.g. within about 1 day, or about 2 days, of the previousadministration of a contemplated co-therapy.

In some embodiments, the daily dosage may include about 5 mg/day toabout 21 mg/day of nicotine and/or about 50 mg/day to about 150 mg/day,or about 50 mg to about 200 mg of opipramol. In this way, the nicotinicagonist may be effective for at least about 1 day, or at least about 3days or more.

The invention further comprises a kit comprising: a) a pharmaceuticalcomposition comprising a nicotine agonist, preferably nicotine, anisomer, pharmaceutically acceptable salt or N-oxide thereof, b) apharmaceutical composition comprising a nAChR desensitization inhibitor,preferably opipramol, a pharmaceutically acceptable salt, ester orprodrug thereof, and c) a leaflet with instructions for administrationof said compositions for treatment of a CNS or PNS disease, disorder orcondition and for induction of smoking cessation. In a preferredembodiment, the kit contains said compositions in the form oftransdermal patches. For this purpose, also provided by the invention isa transdermal patch comprising opipramol.

In another aspect, the present invention provides a combination of anicotinic agonist and a nAChR desensitization inhibitor for treatment ofa CNS or PNS disease, disorder or condition or for induction of smokingcessation.

In a further aspect, the invention relates to the use of a combinationof a nicotinic agonist and a nAChR desensitization inhibitor for thepreparation of a pharmaceutical composition for treatment of a CNS orPNS disease, disorder or condition or for induction of smokingcessation.

In still another aspect, the invention relates to a method of preventionor reduction of the transition of the nAChR to a “desensitized” closedchannel state normally occurring after prolonged exposure to e.g., anicotinic agonist. In this aspect, the invention is directed to methodsfor treatment of nervous system disorder, such as a central nervoussystem disorder or a peripheral nervous system disorder as definedabove, that includes co-administering to a patient in need thereof atherapeutically effective amount of a nicotinic agonist and a nAChRdesensitization inhibitor.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 depicts the effect of opipramol on nicotine-induced calciumuptake in human neuroblastoma cells treated with: 1. growth medium alone(DMEM) containing ⁴⁵Ca²⁺ (without any addition); 2. as 1 with 50 μMnicotine; 3. as 1 with 50 μM nicotine +10 μM opipramol; 4. as (2) butafter incubating the cells for 15 min and treated with 50 μM nicotine+10μM opipramol; and 5. as (2) but after preincubating the cells for 15 minand treated with 50 μM nicotine+10 μM opipramol. Radioactivity ofintracellular ⁴⁵Ca²⁺ was measured after washing the cells with DMEM andexpressed as disintegrations per minute (DPM).

FIG. 2 depicts the effect of opipramol on nicotine-induced smooth musclecontraction using a Guinea pig ileum preparation experiment, wheremuscle contraction is shown as percent of contraction resulting from theaddition of (1) 25 μM nicotine, (2) 25M nicotine in the presence of 10μM opipramol, (3) as (1) but after the muscle was stimulated once with25 μm nicotine; and (4) as (1) but after the muscle was stimulated oncewith 25 μM nicotine in the presence of 10 μM opipramol. Opi=opipramol,Nic=nicotine.

FIGS. 3A-3B depict the effect of 20 mg/kg opipramol on nicotine (2mg/kg) induced hypothermia in rats. FIG. 3A: Each point is theMean±S.E.M. of the change in body temperature compared to thetemperature measured at time 0 (before the first injection) for at leastfive rats. FIG. 3B shows a bar histogram representing mean±S.E.M. of themaximum change in body temperature compared to the temperature measuredjust before the injection. D=day. Injection (Inj) of nicotine (filledcircles), opipramol (triangles), and nicotine+opipramol (filledsquares).

FIGS. 4A-4B depict the effect of opipramol (Opi) (20 mg/kg) orgalantamine (Gal) (5 mg/kg) on nicotine (Nic) (2 mg/kg) inducedhypothermia. FIG. 4A: Each point is the Mean±S.E.M. of change in bodytemperature compared to the temperature measured at time 0 (before thefirst injection) for at least five rats. 4B Bar histogram representingmean±S.E.M. of the maximum change in body temperature compared to thetemperature measured just before the injection.

FIGS. 5A-C depict the effect of opipramol (10 mg/kg) or galantamine (5mg/kg) with nicotine (0.5 mg/kg or 2 mg/kg) on anxiety in rats asassessed by their performance in an elevated plus maze. Bar histogramsrepresent mean of time spent in open arms±S.E.M. 5A: Results of low doseof nicotine (0.5 mg/kg); 5B: Results of high dose of nicotine (2 mg/kg);5C: Comparison between galantamine and opipramol with the low and highdoses of nicotine.

FIG. 6 depicts the effect of opipramol (10 mg/kg) and nicotine (0.5mg/kg) on the expression of brain derived neurotrophic factor (BDNF)mRNA expression in rat cerebral cortex.

FIG. 7 depicts the effect of clomipramine (30 mg/kg) on nicotine-induced(2 mg/kg) hypothermia in rats.

FIGS. 8A-B depicts the effect of lidocaine (15 mg/kg) on nicotine—(2mg/kg) induced hypothermia in rats. The drugs were injected during twodays (day 1 and day 2).

DETAILED DESCRIPTION Definitions

For convenience, certain terms used in the specification, examples, andappended claims are collected in this section.

The term “carrier” refers to a diluent, adjuvant, excipient, or vehiclewith which a contemplated agent or therapeutic is administered. Thecarriers in the pharmaceutical composition may comprise a binder, suchas microcrystalline cellulose, polyvinylpyrrolidone (polyvidone orpovidone), gum tragacanth, gelatin, starch, lactose or lactosemonohydrate; a disintegrating agent, such as alginic acid, maize starchand the like; a lubricant or surfactant, such as magnesium stearate, orsodium lauryl sulphate; a glidant, such as colloidal silicon dioxide; asweetening agent, such as sucrose or saccharin; and/or a flavoringagent, such as peppermint, methyl salicylate, or orange flavoring.

The phrase “combination therapy,” as used herein, refers toco-administering a nicotinic agonist, for example, nicotine, and anicotinic acetylcholine receptor desensitization inhibitor, e.g.,opipramol, as part of a specific treatment regimen intended to providethe beneficial effect from the co-action of these therapeutic agents.The beneficial effect of the combination includes, but is not limitedto, pharmacokinetic or pharmacodynamic co-action resulting from thecombination of therapeutic agents. Administration of these therapeuticagents in combination typically is carried out over a defined timeperiod (usually weeks, months or years depending upon the combinationselected). Combination therapy is intended to embrace administration ofmultiple therapeutic agents in a sequential manner, that is, whereineach therapeutic agent is administered at a different time, as well asadministration of these therapeutic agents, or at least two of thetherapeutic agents, in a substantially simultaneous manner.Substantially simultaneous administration can be accomplished, forexample, by administering to the subject a single tablet or capsulehaving a fixed ratio of each therapeutic agent or in multiple, singlecapsules or tablets for each of the therapeutic agents. Sequential orsubstantially simultaneous administration of each therapeutic agent canbe effected by any appropriate route including, but not limited to, oralroutes, intravenous routes, intramuscular routes, and direct absorptionthrough mucous membrane tissues. The therapeutic agents, e.g. nicotinicagonists and nAChR desensitization inhibitor, can be administered by thesame route or by different routes. For example, a first therapeuticagent of the combination selected may be administered transdermallywhile the other therapeutic agents of the combination may beadministered orally. Alternatively, for example, both therapeutic agentsmay be administered orally or both may be administered transdermally.

Combination therapy can also embrace the administration of thetherapeutic agents as described above in further combination with otherbiologically active ingredients and non-drug therapies. Where thecombination therapy further comprises a non-drug treatment, the non-drugtreatment may be conducted at any suitable time as long as a beneficialeffect from the co-action of the combination of the therapeutic agentsand non-drug treatment is achieved. For example, in appropriate cases,the beneficial effect is still achieved when the non-drug treatment istemporally removed from the administration of the therapeutic agents,perhaps by days or even weeks.

The components of the combination may be administered to a patientsimultaneously or sequentially. It will be appreciated that thecomponents may be present in the same pharmaceutically acceptablecarrier and, therefore, are administered simultaneously. Alternatively,the active ingredients may be present in separate pharmaceuticalcarriers, such as, conventional oral dosage forms, that can beadministered either simultaneously or sequentially.

The term “continuously” as used herein refers to a drug deliveredsubstantially slowly and substantially uninterrupted for e.g. 2, 3, 8,12, or more hours or even 1, 2, 3, 5, 7 or 10 or more days. In someembodiments, the term continuously refers to delivery of a drug or agentthat is substantially longer as compared to bolus single or multipledoses. For this purpose, the transdermal patches according to theinvention are suitable.

The terms, “individual,” “patient,” or “subject” are usedinterchangeably herein and include any mammal, including animals, forexample, primates, for example, humans, and other animals, for example,dogs, cats, swine, cattle, sheep, and horses. The compounds of theinvention can be administered to a mammal, such as a human, but can alsobe other mammals, for example, an animal in need of veterinarytreatment, for example, domestic animals (for example, dogs, cats, andthe like), farm animals (for example, cows, sheep, pigs, horses, and thelike) and laboratory animals (for example, rats, mice, guinea pigs, andthe like).

The term “nicotinic agonist” refers to agents that at least partiallybind and/or activate a nicotinic cholinergic receptor, includingpostganglionic nicotinic receptors, neuroeffector junctions in theperipheral nervous system, and/or at nicotinic receptors in the centralnervous system. The term “nicotinic agonist” is meant to encompassnicotine and other compounds that substantially or at least partiallybind a nicotine receptor and provide a pharmacological effect. The termencompasses the compounds described hereinabove. In addition, it alsoencompasses naturally-occurring compounds (including, but not limitedto, small molecules, polypeptides, peptides, etc., particularlynaturally-occurring plant alkaloids, and the like), endogenous ligands(e.g., purified from a natural source, recombinantly produced, orsynthetic, and further including derivatives and variants of suchendogenous ligands), and synthetically produced compounds (e.g., smallmolecules, peptides, etc.).

The term “indirect nicotinic agonist” refers to agents capable ofincreasing the level of Ach and thus activating the nAChR indirectly.Indirect nicotinic agonists may include reversible choline esteraseinhibitors such as physostigmine, donepezil, tacrine, rivastigmine,pyridostigmine, neostigmine, and the like, and may includenon-reversible choline esterase inhibitors such as echothiphate.

The term “nicotine” is intended to mean the naturally occurring alkaloidknown as nicotine, having the chemical nameS-3-(1-methyl-2-pyrrolidinyl)pyridine, which may be isolated andpurified from nature or synthetically produced in any manner. This termis also intended to encompass nicotine metabolites and derivatives andlike compounds, for example cotinine, norcotinine, nornicotine, nicotineN-oxide, cotinine N-oxide, 3-hydroxycotinine and 5-hydroxycotinine aswell as pharmaceutically acceptable salts thereof e.g. commonlyoccurring salts containing pharmacologically acceptable anions, such ashydrochloride, hydrobromide, hydroiodide, nitrate, sulfate or bisulfate,phosphate or acid phosphate, acetate, lactate, citrate or acid citrate,tartrate or bitartrate, succinate, maleate, fumarate, gluconate,saccharate, benzoate, methanesulfonate, ethanesulfonate,benzenesulfonate, p-toluene sulfonate, camphorate and pamoate salts, aswell as N-oxides, esters or prodrugs thereof.

The term “nicotinic acetylcholine receptor desensitization inhibitor” or“nAChR desensitization inhibitor” refers to an agent that at leastpartially reduces, inhibits, or retards nicotinic acetylcholine receptordesensitization, for example at least partially reduces thedesensitization caused by repeated (e.g. two or more doses)administration of nicotine to a patient. Such nAChR desensitizationinhibitors may attenuate nAChR desensitization from a slight decrease tofull inhibition (i.e. no apparent reduction in nicotinic action betweenthe first application of a nicotinic agonist and consequent repeatedapplications of said agonist).

The term “therapeutically effective” refers to the ability of an activeingredient, alone or in combination with another active agent, to elicitthe biological or medical response that is being sought by a researcher,veterinarian, medical doctor or other clinician.

The term “therapeutically effective amount” includes the amount of anactive ingredient, or combination of active ingredients, that willelicit the biological or medical response that is being sought by theresearcher, veterinarian, medical doctor or other clinician. Thecompounds of the invention are administered in amounts effective fortreating a CNS or PNS disorder. Alternatively, a therapeuticallyeffective amount of an active ingredient is the quantity of the compoundrequired to achieve a desired therapeutic and/or prophylactic effect,such as the amount of the active ingredient that results in theprevention of or a decrease in the symptoms associated with thecondition (for example, to meet an end-point).

The terms “cognitive disorder” or “cognitive dysfunction” refer tomental conditions that cause patients to have difficulty in thinkingwith symptoms generally marked by impaired attention, perception,reasoning, memory and judgment. One type of cognitive disorder isdementia, which is characterized by gradual impairment of multiplecognitive abilities including memory, language and judgement. Memorydeficit and dementia states can be caused by, or associated with,neurodegenerative or neurological diseases, disorders or conditions suchas Alzheimer's disease, Parkinson's disease, Huntington's disease, Lewybody disease, Pick's disease, Jakob-Creutzfeld disease, multiplesclerosis, anxiety, depression, schizophrenia, limbic encephalitis,normal pressure hydrocephalus, age-related memory impairment; braindamage caused by stroke, brain injuries and vascular dementia;infectious diseases such as neurosyphilis, acquired immune deficiencysyndrome (AIDS), fungal infections, tuberculosis; drug intoxication suchas alcohol, nicotine, cannabis, and cocaine addiction or heavy metalexposure. Attention deficit disorder (ADD) and attention deficithyperactivity disorder (ADHD) are types of cognitive dysfunction foundboth in children and adults.

The term “treating” is used herein to denote treating the disease,disorder or condition, or ameliorating, alleviating, reducing, orsuppressing symptoms of the disease, or slowing or stopping the progressof the disease. Thus, in some embodiments, administration of thecomposition or combination of the invention may ameliorate, alleviate orreduce the cognitive disorder symptoms in dementia associated with thediseases, disorders and conditions as mentioned above.

The terms “pharmaceutically acceptable” or “pharmacologicallyacceptable” refer to molecular entities and compositions that do notproduce an adverse, allergic or other untoward reaction whenadministered to an animal, or to a human, as appropriate. The term,“pharmaceutically acceptable carrier” includes any and all solvents,dispersion media, coatings, antibacterial and antifungal agents,isotonic and absorption delaying agents and the like. The use of suchmedia and agents for pharmaceutical active substances is well known inthe art. Except insofar as any conventional media or agent isincompatible with the active ingredient, its use in the therapeuticcompositions is contemplated. Supplementary active ingredients can alsobe incorporated into the compositions.

Pharmaceutically acceptable salts of the disclosed compounds can besynthesized, for example, from the parent compound, which contains abasic or acidic moiety, by conventional chemical methods. Generally,such salts can be prepared by reacting the free acid or base forms ofthese compounds with a stoichiometric amount of the appropriate base oracid in water or in an organic solvent, or in a mixture of the two;generally, non-aqueous media like ether, ethyl acetate, ethanol,isopropanol, or acetonitrile. Lists of suitable salts are found inRemington's Pharmaceutical Sciences, 20th ed., Lippincott Williams &Wilkins, Baltimore, Md., 2000, p. 704.

The term “prodrug” refers to compounds that are transformed in vivo toyield a disclosed compound or a pharmaceutically acceptable salt,hydrate or solvate of the compound. The transformation may occur byvarious mechanisms, such as through hydrolysis in blood. For example, ifa nAChR desensitization inhibitor, or a pharmaceutically acceptablesalt, hydrate or solvate of this compound contains a carboxylic acidfunctional group, a prodrug can comprise an ester formed by thereplacement of the hydrogen atom of the acid group with a group such as(C₁-C₈)alkyl, (C₂-C₁₂)alkanoyloxymethyl, 1-(alkanoyloxy)ethyl havingfrom 4 to 9 carbon atoms, 1-methyl-1-(alkanoyloxy)-ethyl having from 5to 10 carbon atoms, alkoxycarbonyloxymethyl having from 3 to 6 carbonatoms, 1-(alkoxycarbonyl-oxy)ethyl having from 4 to 7 carbon atoms,1-methyl-1-(alkoxycarbonyloxy)ethyl having from 5 to 8 carbon atoms,N-(alkoxycarbonyl)aminomethyl having from 3 to 9 carbon atoms,1-(N-(alkoxycarbonyl)amino)ethyl having from 4 to 10 carbon atoms,3-phthalidyl, 4-crotonolactonyl, gamma-butyrolacton-4-yl, di-N,N—(C₁-C₂)alkylamino(C₂-C₃)alkyl (such as P-dimethylaminoethyl), carbamoyl-(C₁-C₂)alkyl, N,N-di(C₁-C₂)alkylcarbamoyl-(C₁-C₂)alkyl and piperidino-,pyrrolidino- or morpholino(C₂-C₃)alkyl.

Similarly, if a nicotinic agonist or nAChR desensitization inhibitorcontains an alcohol functional group, a prodrug can be formed by thereplacement of the hydrogen atom of the alcohol group with a group suchas (C₁-C₆)alkanoyl-oxymethyl, 1-(C₁-C₆)alkanoyloxy)ethyl,1-methyl-1-(C₁-C₆)alkanoyloxy) ethyl (C₁-C₆)alkoxycarbonyloxymethyl,N—(C₁-C₆)alkoxycarbonylaminomethyl, succinoyl, (C₁-C₆)alkanoyl,α-amino(C₁-C₄)alkanoyl, arylacyl and α-aminoacyl, orα-amino-acyl-α-aminoacyl, where each α-aminoacyl group is independentlyselected from the naturally occurring L-amino acids, P(O)(OH)₂,—P(O)(O(C₁-C₆)alkyl)₂ or glycosyl (the radical resulting from theremoval of a hydroxyl group of the hemiacetal form of a carbohydrate).

If a nAChR desensitization inhibitor or nicotinic agonist incorporatesan amino functional group, a prodrug can be formed by the replacement ofa hydrogen atom in the amino group with a group such as R-carbonyl,RO-carbonyl, NRR′-carbonyl where R and R′ are each independently(C₁-C₁₀)alkyl, (C₃-C₇)cycloalkyl, benzyl, or R-carbonyl is a naturalα-aminoacyl or natural α-aminoacyl-natural α-aminoacyl, —C(OH)C(O)OY₁wherein Y₁ is H, (C₁-C₆)alkyl or benzyl, —C(OY₂)Y₃ wherein Y₂ is (C₁-C₄)alkyl and Y₃ is (C₁-C₆)alkyl, carboxy(C₁-C₆)alkyl, amino(C₁-C₄)alkyl ormono-N— or di-N,N—(C₁-C₆)alkylaminoalkyl, —C(Y₄)Y₅ wherein Y₄ is H ormethyl and Y₅ is mono-N— or di-N,N—(C₁-C₆)alkylamino, morpholino,piperidin-1-yl or pyrrolidin-1-yl.

The term “transdermal delivery” refers to drug delivery across the skin,usually accomplished without breaking the skin.

Methods

Provided herein are methods of treating CNS and PNS diseases, disordersor conditions using disclosed compositions or formulations. In someembodiments, a disclosed method provides for an effect of a subsequentadministration of a nicotinic agonist, after, e.g. a firstadministration of nicotinic agonist and nAChR desensitization inhibitor,to said patient is substantially more therapeutically effective ascompared to, e.g. a subsequent administration of a nicotinic agonist, ora nicotinic agonist and a nAChR desensitization inhibitor using a methodfor treatment consisting of first administrating to said patient anicotinic agonist alone. For example, in some embodiments, the nAChRdesensitization inhibitor of the disclosed combination may reducedesensitization of an administered nicotinic agonist for at least about3 hours, at least about 6 hours, at least about 12 hours, or at leastabout one, two, three days, or about 1 week or more.

Also provided herein are methods of treating CNS and PNS diseases suchas those above, that may provide for an effect of a subsequentadministration of an indirect nicotinic agonist, after e.g. a firstadministration of indirect nicotinic agonist and nAChR desensitizationinhibitor.

In another embodiment, a method provides for substantially prolongednicotinic agonist effect following said co-administering in saidpatient, for example, as compared to the nicotinic effect obtained byadministering to a patient a nicotinic agonist alone. For example, thedisclosed methods may provide a nicotinic agonist effect, afterco-administration, that is about, e.g. 1.5 times, twice or even threetimes as effective or 1.5 times, twice, or even three times prolonged ascompared to administering the nicotinic agonist alone.

Disclosed methods comprise, for example, a combination therapy, whichcan be achieved by co-administering to a patient a nicotinic agonist anda nAChR desensitization inhibitor. The nicotinic agonist and a nAChRdesensitization inhibitor can be administered as a (i) single dosageform or composition, (ii) simultaneously as separate dosage forms orpharmaceutical compositions, (iii) sequentially, as separate dosageforms starting with the nicotinic agonist and then administering nAChRdesensitization inhibitor, or starting with the nAChR desensitizationinhibitor and then administering the nicotinic inhibitor, (iv)successively, separated by for example about 10 minutes to about 4hours, about 1-4 hours, about 1-8 hours, about 1 hour to about 12 or 24or more hours, or more or (v) individually followed by the combination.The methods disclosed herein may occur before, during, or after otherdosing regimens that may include, for example nicotinic agonists, anAChR desensitization inhibitor, and other agents e.g., for treating CNSor PNS diseases, disorders or conditions. In an embodiment, a disclosedmethods may comprise a combination therapy, which can be achieved byco-administering to a patient an indirect nicotinic agonist and a nAChRdesensitization inhibitor.

For example, a nAChR desensitization inhibitor, in some embodiments, maybe administered prior to, concomitantly with, or shortly after,administration of the nicotinic agonist. In an embodiment, a nAChRdesensitization inhibitor may be administered concomitantly with thenicotinic agonist, for example in the same composition. For example, inan embodiment, the nAChR desensitization inhibitor may be administeredorally, and the nicotinic agonist is administered transdermally. Forexample, administration of nicotine may be less suitable for oraldelivery because it may, for example, cause unacceptable adverse events,and/or may be absorbed from the gut into the portal blood and degradepromptly by the liver. In certain embodiments, however, the nAChRdesensitization inhibitor can be administered with nicotinic agonist indosage forms that deliver nicotinic agonist to the systemic circulationvia absorption through mucosal membranes or the skin, including dosageforms such as chewing gum, thin films (e.g. orally dissolving thinfilms), sachets, transdermal patches, capsules, tablets, lozenges, nasalsprays and oral inhalation devices.

Alternatively, the nicotinic agonist and the nAChR desensitizationinhibitor may be administered topically or transdermally (e.g. via atransdermal patch) to a patient. For example, the nAChR desensitizationinhibitor and/or the nicotinic agonist may be administered to a patientsubstantially continuously, e.g. by transdermal patch and/or by asustained release composition. For example, the nicotinic agonist andthe nAChR desensitization inhibitor may be administered via onetransdermal patch (e.g., substantially continuously), or the nicotinicagonist may be administered in a first transdermal patch and the nAChRdesensitization inhibitor may be administered in a second transdermalpatch, which is different than the first (e.g., both may be administeredsubstantially continuously via two patches, or the first patch may havea different delivery rate than the second patch, and/or the first patchmay have a different surface area as compared to the second patch). Inan embodiment, a first patch may be placed at one location on a patientand the second patch may be placed at another location which may besubstantially near the first patch or may be at a substantiallydifferent location.

In another embodiment, the nicotinic agonist and nAChR desensitizationinhibitor may be administered to a patient in a substantially continuousmanner, e.g., provide substantially steady amounts over 1 day, 3 days, 1week, 10 days, or more. In another embodiment, disclosed methods mayfurther comprise re-administering to the patient a therapeuticallyeffective amount of a nicotinic agonist and an AChR desensitizationinhibitor, for example, within about 12 hours, 1 day, 2 days or more, ofthe previous administration.

In some embodiments, the nicotinic agonist is administered in escalatingdoses. Such escalating doses may comprise a first dose level and asecond dose level. In other embodiments, escalating doses may compriseat least a first dosage level, a second dosage level, and a third dosagelevel, and optionally a fourth, fifth, or sixth dosage level. Thenicotinic acetylcholine receptor desensitization inhibitor may beprovided in one dosage level when in administered in combination with anicotinic agonist, or may be administered in escalating doses.

A first, second, third or more dosage levels can be administered to apatient for about 2 days to about 6 months or more in duration. Forexample, first, second and/or third dose levels are each administered toa subject for about 1 week to about 26 weeks, or about 1 week to about12 weeks, or about 1 week to about four weeks. Alternatively, the first,second and/or third dosage levels are administered to a subject forabout 2 days to about 40 days or to about 6 months.

The nicotinic agonist may be administered in a therapeutically effectiveamount. In some embodiments the contemplated therapeutically effectivedosages of a nicotinic agonist, while not effective when used inmonotherapy, may be effective when used in the combinations disclosedherein.

Exemplary methods contemplated herein and comprising administering to apatient a disclosed composition or dosage form or combination therapyinclude methods of treating Alzheimer's disease, Parkinson's disease,schizophrenia, attention deficit hyperactivity disorder (ADHD),attention deficit disorder (ADD), vascular dementia, Lewy body disease,post-traumatic dementia, Pick's disease, multiple sclerosis,Jakob-Creutzfeldt disease, nicotine addiction, alcohol addiction,cannabis addiction, cocaine addiction, obsessive disorders, compulsivedisorders, impulse-control disorders, neurological conditions associatedwith acquired immune deficiency syndrome (AIDS), aging and/orHuntington's disease. In another embodiment, a method for managingand/or treating pain in a patient is provided. In some embodiments, amethod of treating a cognitive disorder or dysfunction is contemplated,comprising administering to a patient a disclosed composition or dosageform, for example, a method of treating dementia, Alzheimer's disease,Parkinson's disease, schizophrenia, or nicotine or other addiction. Inan embodiment, a method is also provided for treating and/orameliorating mild cognitive impairment e.g. a patient in early stages ofAlzheimer's disease.

The present invention, in some embodiments, provides a method forsmoking cessation, comprising administering to a smoking individual adisclosed composition, e.g. a composition comprising nicotine and acompound capable of reducing the nAChR desensitization caused by thenicotine. In other embodiments, provided herein are methods for treatinganxiety, depression, restless legs syndrome, Tourette's syndrome,chronic tic disorder, or essential tremor, comprising administering to apatient a disclosed composition or dosage form or combination therapy. Amethod is also provided for treating behavioral e.g. compulsivedisorders, such as obsessive-compulsive disorder and/or generalizedanxiety disorders.

Also disclosed is a method for slowing or ameliorating the progressionof Parkinson's disease, for example, upon administration, the nicotinicagonist may act as a neuroprotective agent, wherein the neuroprotectiveeffect may be enhanced by e.g. co-administration of a nAChRdesensitization inhibitor.

In a particular embodiment, methods are disclosed that provide treatingor suppressing tobacco or nicotine dependence or usage, said methodcomprising administering to a human a disclosed composition or dosageform or combination therapy. Also provided are methods of treating drugaddiction, dependence or tolerance to stimulants such as nicotine,cannabis or cocaine, comprising administering to a patient a compositionor dosage form or combination therapy.

Also provided herein are methods for increasing blood flow to ischemictissue in patient, comprising administering a disclosed composition ordosage form or combination therapy effective to stimulate angiogenesisand increase blood flow to the ischemic tissue. Contemplated herein, inan embodiment, are methods for providing neuronal protection, e.g. fromoxidative stress, or such methods may provide for e.g. delayed death ofe.g. hippocampal neurons that may be e.g. ischemia induced. For example,in an embodiment, a method for treating and/or ameliorating stroke in apatient who is at risk of, or who has had a stroke or other vasculardisease, is provided herein. Also provided herein are methods fortreating and/or ameliorating diseases related to neuronal death (forexample motor neuron death), e.g. amyotrophic lateral sclerosis.

Also provided herein are methods for treating peripheral nervousdisorders such as carpal tunnel syndrome, Guillain-Barre syndrome, ordiabetic, amyloid, and/or brachial plexus neuropathies, comprisingadministering disclosed compounds, co-therapies, and/or dosage forms.

For example, a method for increasing the efficacy of a nicotinic agonistby inhibiting or reducing the desensitization of nAChRs in an individualbeing treated with said nicotinic agonist is provided, which comprisesco-administering to the individual a therapeutically effective amount ofa compound capable of reducing the nAChR desensitization, thusincreasing the efficacy of the nicotinic agonist.

Disclosed methods of e.g., treating a CNS or PNS disease, disorder orcondition may, in some embodiments, further include administering adesensitization inhibitor of a receptor other than nAChR. In someembodiments, for example, such an inhibitor may be the same or differentthan the nAChR desensitization inhibitor contemplated herein.

In an exemplary embodiment, the nAChR desensitization inhibitor is atricyclic antidepressant such as opipramol or imipramine, or atetracyclic antidepressant such as galantamine (a tetracyclic alkaloid),an inhibitor of acetylcholine esterase, mirtazapine, or maprotiline. Inanother embodiment, the nAChR desensitization inhibitor is McN-A-343, adrug that may selectively activate certain subclasses of muscarinicreceptors.

Compositions and Formulations

Compositions provided herein may include at least one nicotinic agonist,at least one nAChR desensitization inhibitor, and a pharmaceuticallyacceptable carrier. In an exemplary embodiment, a pharmaceuticalcomposition comprises nicotine and opipramol, or its pharmaceuticallyacceptable salts, esters and/or prodrugs thereof. In other embodiments,the pharmaceutical composition may comprise nicotine and galantamine,clomipramine, lidocaine or McN-A-343.

In some embodiments, the disclosed compositions may include a nicotinicagonist (e.g. nicotine) and a nAChR desensitization inhibitor (e.g.opipramol) in a weight ratio of nicotinic agonist:nAChR desensitizationinhibitor of about 1:100 to about 100:1, e.g., about 1:1 to about 1:50,about 1:1 to about 1:5, 1:5 to about 1:50, about 1:5 to about 1:20, orabout 1:10 to about 1:15, e.g. about 1:14, or about 1:13.

The pharmaceutical compositions may be in any suitable form includingforms for oral, parenteral, transcutaneous, mucosal, or inhalationadministration. In some embodiments, the compositions may beadministered in the form of chewing gum, sachets, transdermal patches,capsules, tablets, lozenges, or nasal sprays.

For topical administration, the disclosed compositions may beadministered in the form of a gel, a cream, a paste, a lotion, a spray,a suspension, a powder, a dispersion, a salve and an ointment.

In some embodiments, the composition for transdermal delivery is atransdermal ointment, cream, gel, lotion or other transdermal solutionor suspension. Preferably, for transdermal delivery, a transdermal patchcan be used that may be a single layer drug in adhesive patch, amulti-layer drug in adhesive patch, a reservoir patch, a matrix patch, amicroneedle patch or an iontophoretic patch, which typically requiresapplying a direct current. For example, a transdermal delivery system(patch) may be used, such as a transdermal nicotine delivery devicedescribed in U.S. Pat. No. 4,839,174. The compositions for transdermaldelivery including the patches may include a skin penetration enhanceras known in the art. In still further embodiments, the transdermal patchis adapted for sustained release.

In certain embodiments, the disclosed compositions may be administeredorally. For oral administration, the active ingredients may take theform of solid dose forms, for example, tablets (both swallowable andchewable forms), capsules or gel caps, prepared by conventional meanswith pharmaceutically acceptable excipients and carriers such as bindingagents (e.g. pregelatinised maize starch, polyvinylpyrrolidone,hydroxypropylmethylcellulose and the like), fillers (e.g. lactose,microcrystalline cellulose, calcium phosphate and the like), lubricants(e.g. magnesium stearate, talc, silica and the like), disintegratingagents (e.g. potato starch, sodium starch glycollate and the like),wetting agents (e.g. sodium laurylsulphate) and the like. Such tabletsmay also be coated by methods well known in the art. Alternatively, apharmaceutical preparation may be in liquid form, for example,solutions, syrups or suspensions, or may be presented as a drug productfor reconstitution with water or other suitable vehicle before use. Suchliquid preparations may be prepared by conventional means withpharmaceutically acceptable additives such as suspending agents (e.g.,sorbitol syrup, cellulose derivatives or hydrogenated edible fats);emulsifying agents (e.g., lecithin or acacia); non-aqueous vehicles(e.g., almond oil, oily esters, or fractionated vegetable oils); andpreservatives (e.g., methyl or propyl p-hydroxybenzoates or sorbicacid).

The disclosed compositions may be administered as single or multipledoses in any suitable form as described above or they may beadministered substantially continuously through a drug delivery deviceor a sustained release composition. For example, a sustained releasecomposition may include such excipients as poly(lactide-co-glycolide)e.g., microparticles of PLGA; polyacrylate, latex, starch, cellulose,dextran and the like, supramolecular biovectors, which comprise anon-liquid hydrophilic core (e.g., a cross-linked polysaccharide oroligosaccharide) and, optionally, an external layer comprising anamphiphilic compound, such as a phospholipid (see e.g., U.S. Pat. No.5,151,254, WO 94/20078, WO/94/23701 and WO 96/06638), biodegradablemicrospheres (e.g., polylactate polyglycolate) (see e.g. U.S. Pat. Nos.4,897,268; 5,075,109; 5,928,647; 5,811,128; 5,820,883; 5,853,763;5,814,344, 5,407,609 and 5,942,252.) and calcium phosphate coreparticles.

Contemplated dosages of a nicotinic agonist for use in the disclosedmethods and compositions should be large enough to produce the desiredeffect, whereby, for example, desensitization of the nAChR issubstantially prevented and the action of the nicotinic agonist isprolonged, and further, where the symptoms of the disease, disorder orcondition are substantially reduced or ameliorated. The doses should notbe so large as to cause adverse side effects. In some embodiments, atherapeutically effective amount of nicotinic agonist may range from 1to 100 mg per patient. For example, nicotine may be administered atabout 5 mg/day to about 21 mg/day, or about 10 mg/day to about 21mg/day, or about 15 mg/day, 20 mg/day, or about 7 mg/day. In otherembodiments, a nictonic agonist, e.g., nicotine is administered fromabout 0.05 mg/kg/day to about 5 mg/kg/day. In situations where anicotinic agonist is administered continuously, the dosage may, in someembodiments, be kept in the lower ranges to avoid undesiredside-effects.

Opipramol may be, for example, administered at dosage of about 50 mg orabout 100 mg/day, e.g. about 10 mg/day to about 300 mg/day, about 50mg/day to about 200 mg/day, about 50 mg/day to about 150 mg/day or about50 mg/day to about 250 mg/day. For example, 200 mg/day, or 125 mg/day,150 mg/day or 250 mg/day of opipramol may be administered. In anotherembodiment, opipramol may be administered from about 0.2 mg/kg/day toabout 20 mg/kg/day.

In some embodiments, lidocaine may be administered from about 0.1mg/kg/day to about 10 mg/kg/day. For example, a total dose forpercutaneous administration may be about 5 to about 300 mg.

The present invention also relates to the use of a compound capable ofreducing nAChR desensitization caused by a nicotinic agonist, for thepreparation of a medicament comprising also a nicotinic agonist or foradministration with a medicament comprising a nicotinic agonist, fortreatment of a disease, disorder or condition responsive to theadministration of a nicotinic agonist.

The present invention also provides for a package or kit for treatmentof a disease, disorder or condition responsive to the administration ofa nicotinic agonist, e.g., a CNS or PNS disease, disorder or condition,said kit comprising a pharmaceutical composition comprising a nicotinicagonist, a pharmaceutical composition comprising a nAChR desensitizationinhibitor, and a leaflet with instructions for administration of saidcompositions for treatment of a disease, disorder or conditionresponsive to the administration of a nicotinic agonist.

The pharmaceutical compositions of the kit may be comprised each in onecontainer and the kit will comprise two containers, a first containercontaining a nicotinic agonist and a pharmaceutically acceptable carrierand the second container containing a nAChR desensitization inhibitorand a pharmaceutically acceptable carrier, and the leaflet. The twopharmaceutical compositions may be in similar formulation form, forexample, each is in the form of a transdermal patch, or in differentformulation forms, for example, one is presented as a transdermal patchand the other is presented as oral form. For example, nicotine may becomprised within a transdermal patch and opipramol as tablets. Inanother embodiment, the kit includes a first dosage form, e.g. atransdermal patch, that includes a nicotinic agonist (e.g., nicotine),and a second dosage form, e.g. a transdermal patch that includes a nAChRdesensitization inhibitor (e.g., opipramol), and instructions for use

Also provided is controlled release medical device for delivery of acomposition comprising a) nicotine, b) opipramol or pharmaceuticallyacceptable salts, esters, and prodrugs thereof; which is capable ofdelivering the composition in a pre-determined delivery rate to apatient. In one embodiment, the pre-determined delivery rate issubstantially continuously over at least 1 day.

The examples that follow are intended in no way to limit the scope ofthis invention but are provided to illustrate the methods of the presentinvention. Many other embodiments of this invention will be apparent toone skilled in the art.

EXAMPLES Materials and Methods

(i) Cells —SK-N—SH human neuroblastoma cell line was obtained from theAmerican Type Culture Collection (ATTC).

(ii) Animals—Young adult (240 g-290 g) male Sprague-Dawley rats (CharlesRiver, USA or Harlan, Israel) were used in the experiments.

(iii) Drugs—Nicotine (Sigma); opipramol (Rafa Laboratories Ltd.Jerusalem, Israel), McN-A-343(4-(N-[3-chlorophenyl]-carbamoyloxy}-2-butynyl-trimethylammoniumchloride—from R.B.I, USA), galantamine (Sigma, Israel), lidocaine(Sigma) and clomipramine (Sigma) were dissolved in 0.9% saline solutionbefore use.

(iv) Determination of nicotine-induced hypothermia—Rats were placedindividually in experimental cages kept at 25° C. and were allowed torest for 1 h before drug injection. During this period, body temperaturewas measured at 15- or 30-min intervals in order to exclude the effectof handling on animal temperature. Body temperature was measured with arectal thermistor probe (M.R.C, Israel, sensitivity 0.1° C.). The probewas lubricated with petroleum before being inserted into the rectum to adepth of 2 cm. The data are presented as changes in rectal temperaturefrom the basal values. Basal values are those taken immediately beforethe drug injection (time 0).

(v) Elevated Platform Maze (EPM)—The purpose of the EPM is to determinethe anxiolytic effects of tested drugs. The time that the experimentalanimals spend in the open arm of the maze is an indication for theanxiolytic effect, the longer the time the higher the anxiolytic effect.The EPM is a wooden, cross-shaped device, consisting of four armsarranged in the shape of a plus sign. Two of the arms have no side orend walls (open-arms; 30×5×0.25 cm). The other two arms have side wallsand end walls, but are open on top (closed arms; 30×5×15 cm). The mazeis elevated to a height of 50 cm. The animals are kept in a relativelydark box before exposure to the maze in order to increase theirexploratory behavior. The tests were done in a silent environment underdim light. The animals were carried to the laboratory and left thereundisturbed for 1 h before the experiment. Each rat was individuallyplaced on the central platform 5×5 facing toward an open-arm and wasobserved for 5 min by two observers sitting in the same room, recordingthe time that the animals spent in the open arm.

(vi) Statistical analysis—The results are expressed as means±S.E.M ofthe data obtained from all the animals in each treatment group. Theresults were analyzed using ANOVA (α=0.05) or Student t-test whenappropriate.

Example 1 Effect of Opipramol and MCN-A-343 on Nicotine-Induced CalciumInflux in Cultured Cells

SK-N-SH human neuroblastoma cells, known to express nAChR, were grown inDulbecco/Vogt Modified Eagle's Minimal Essential Medium (DMEM) toconfluency in a 24-well plate. DMEM containing 45Ca+ without any otheraddition (1) or with 50 μM nicotine (2) or with 50 μM nicotine +10 μMopipramol (3) was added to cells grown in 24-well plates andpreincubated with medium alone for 15 minutes, then washed rapidly.Intra cellular radioactivity was determined for each condition. The samemedium with nicotine was added also to cells that were preincubated for15 minutes with either 50 μM nicotine alone (4) or with 50 μM nicotine+10 μM opipramol (5). 45Ca2+ uptake was determined after 10 min.Activation of the nicotinic receptors causes calcium influx so it is ameasure of the nicotinic receptor activity.

The results with opipramol are shown in FIG. 1. The first exposure tonicotine caused an increase in calcium influx (2) compared to basaluptake in the absence of nicotine (1). Simulation of the cells for thefirst time with nicotine in the presence of opipramol, also caused asignificant rise in calcium uptake (3) which was only slightly smallercompared to that obtained with first stimulation with nicotine alone.However, when the cells were exposed to nicotine for the second time(4), calcium influx was considerably reduced due to nAChR receptordesensitization. By comparison, when the cells were stimulated withnicotine and opipramol during the first stimulation only a slightdecrease in 45Ca2+ uptake was observed and in the second stimulationnAChR desensitization was remarkedly reduced (5), indicating thatopipramol reduces receptor desensitization. DPM, disintegrations perminute. Similar results were obtained when 10 μM Mc-N-A-343 was usedinstead of opipramol (not shown).

Example 2 Effect of Opipramol on Nicotine-Induced Smooth MuscleContraction and on Nicotine Induced Desensitization in the Guinea PigIleum Preparation

The free end of a smooth muscle of a guinea pig ileum was attached to aforce displacement transducer. Isometric tension of the smooth musclewas continuously monitored by outputting the preamplified transducersignal to a computer. Addition of 25 μM nicotine caused musclecontraction. The peak obtained with this concentration of nicotine wasquantified by the displacement transducer and was normalized and definedas 100% contraction as shown in left black bar in FIG. 2 (1ststimulation; bar 1).

Opipramol reduced the effect of nicotine to about 50% of that induced bynicotine alone (1st stimulation; bar 2). The ileum preparation waswashed by physiological solution 10 min after the addition of nicotineand then nicotine at a final concentration of 25 μM was added again tothe muscle preparation for additional 10 min (2nd stimulation; bar 3).As can be seen, nicotine did not induce muscle contraction during thesecond stimulation (2nd stimulation; bar 4) due to receptordesensitization. However, if the first stimulation was done in thepresence of opipramol (as described by bar 2 in the 1st stimulation),nicotine induced almost full response during the second stimulation (bar4), indicating that opipramol prevented or reduced the nAChRdesensitization.

When nicotine was administered together with opipramol the effect ofnicotine was maintained steady for one hour until the removal of thedrugs by washing (data not shown) indicating that opipramol effectivelyprevents nAChR desensitization.

Example 3 Effect of Opipramol on Nicotine-Induced Hypothermia in Rats

Rats were divided into three treatment groups, each of 5 rats, asfollows: 1. treatment with nicotine (2 mg/kg); 2. treatment withopipramol (20 mg/kg); 3. treatment with opipramol (20 mg/kg) togetherwith nicotine (2 mg/kg). Rats were injected with nicotine twice on thefirst day (FIG. 3A, D-1, left panel) and three times on days 2 (FIG. 3A,D-2, middle panel) and 3 (FIG. 3A, D-3, right panel). The intervalsbetween the injections were 3 hours according to the time needed forreturning to normal body temperature. Nicotine was injected with andwithout opipramol, and body temperature was measured at 30 minintervals. The results are shown in FIG. 3. (FIG. 3A: Filledcircles—Rats injected with nicotine (2 mg/kg) three times a day inintervals of 3 hours for three consecutive days (N=5); Inversedtriangles—Rats injected with opipramol (20 mg/kg) three times a day inintervals of 3 hours for three consecutive days (N=5); Filledsquares—Rats injected with nicotine (2 mg/kg) and opipramol (20 mg/kg)three times a day in intervals of 3 hours for three consecutive days(N=5). D, day; Inj., Injection; Opi, opipramol; Nic, nicotine.) Whennicotine (2 mg/kg) was repeatedly injected for three consecutive days,the magnitude of the decrease in body temperature induced by a constantdose of nicotine became progressively smaller (P<0.05), indicatingdesensitization of the nAChR. When opipramol was injected together withnicotine in the second and the third day, the magnitude of the reductionin body temperature was significantly larger than that induced bynicotine alone (P<0.001) after the second and the third injections.Opipramol alone caused only a slight decrease in body temperature. FIG.3A: Each point is the Mean±S.E.M. of change in body temperature comparedto the temperature measured at time 0 (before the first injection) forat least five rats. FIG. 3B depicts a bar histogram representingmean±S.E.M. of the maximum change in body temperature compared to thetemperature measured just before the injection.

Example 4 Effect of Opipramol or Galantamine on Nicotine-InducedHypothermia in Rats

Following a similar protocol to that of Example 3, opipramol (20 mg/kg)or galantamine (5 mg/kg) were injected with and without nicotine. Bodytemperature was recorded at 30 min intervals. FIG. 4 depicts theresults. FIG. 4A: Each point is the Mean±S.E.M. of change in bodytemperature compared to the temperature measured at time 0 (before thefirst injection) for at least five rats. 4B Bar histogram representingmean±S.E.M. of the maximum change in body temperature compared to thetemperature measured just before the injection.

Example 5 Effect of Repeated Nicotine Administration on Anxiety in Rats

This test is used to assess anxiety. Rats were randomly assigned intofive groups each containing 5 animals and then tested in an ElevatedPlus Maze (EPM). In the first (control) group, rats were injected withsaline once a day; in the second group rats were injected with nicotine(0.5 mg/kg or 2 mg/kg) three times a day and were tested in the mazeafter the third injection; in the third group rats were injected withopipramol (10 mg/kg) three times a day and then were tested in the maze;in the fourth group, rats were injected with opipramol (10 mg/kg) orgalantamine (5 mg/kg), and nicotine (2 mg/kg or 0.5 mg/kg) three times aday and were tested in the maze after the last injection. The behavioralresponse to nicotine in the EPM was assessed 30 min after the firstinjection, and then again 30 minutes after the third injection. As canbe seen from FIG. 5, one injection of nicotine significantly increasedthe time that the rats spent in the open arm, indicating the anxiolyticeffect of nicotine. However, nicotine at both doses 0.5 mg/kg and 2mg/kg did not induce an anxiolytic effect during the second injectiondue to receptor desensitization. When nicotine was injected togetherwith either galantamine or opipramol, the anxiolytic effect was seen inthe second injection (at 0.5 mg/kg nicotine), indicating that bothgalantamine and opipramol inhibited nAChR desensitization. Opipramolappears more effective in this test as it also inhibited desensitizationwhen the dose of nicotine was raised to 2 mg/kg. Galantamine was noteffective in inhibiting nAChR desensitization at this nicotine dose. Barhistograms represents mean of time spent in open arms±S.E.M. FIG. 5Adepicts the results of low dose of nicotine (0.5 mg/kg), FIG. 5B depictshigh dose of nicotine (2 mg/kg), FIG. 5C shows a comparison betweengalantamine and opipramol with different doses of nicotine.

Example 6 Effect of Nicotine and Opipramol on BDNF mRNA Expression inRat Cortex

Nicotine alone (0.5 mg/kg) or opipramol (10 mg/kg) or nicotine (0.5mg/kg)+opipramol (10 mg/kg) were injected intraperitoneally (ip) to rats(5 per group) at intervals of 2 hours during a single day. The drugswere dissolved in saline and used in the same day. Each injection had avolume of 1 ml/kg body weight. Animals were sacrificed 90 min after eachinjection and brain derived neurotrophic factor (BDNF) and β-actin mRNAwere determined in homogenates of the cerebral cortex of each animal.

Homogenates of the cerebral cortex were prepared as follows: Rat braintissues were sonicated for 15 sec and total RNA was obtained using theTrizol Reagent (Molecular Research Center, Cincinnati, Ohio, USA),according to the manufacturer's instructions. RNA concentrations werequantified by measuring the absorbances at 260 and 280 nm. RNA wasreverse transcribed into cDNA during 45 min at 42° c. The cDNA productswere diluted 1:40 for BDNF and 1:1000 for β-actin (a housekeeping genefor internal standard). In order to amplify gene specific sequences, PCRtechniques were applied using ReadyMix PCR Master Mix (AB-genes, Surrey,UK) and specific primer sequences for BDNF and beta actin. The productswere separated by electrophoresis on agarose and quantification of thebands was done by an image analyzer.

FIG. 6 depicts results (mean±SEM of the ratio of BDNF mRNA levels/βactin) of injections of a control (saline), nicotine alone (first andthird injections), opipramol alone (third injection) andopipramol/nicotine injection (third injection). As can be seen, BDNFmRNA is increased as a result of treatment of the animals with nicotine.A repeated injection of nicotine was accompanied with a much smallerrise in BDNF mRNA as a result of nAChR desensitization. However, whennicotine was injected together with opipramol, the desensitization ofthe nAChR was inhibited and BDNF mRNA level was rising even above thatwhich was observed with nicotine alone, indicating that opipramol canenhance the effect of nicotine and inhibit nAChR desensitization.Opipramol alone had no effect on the level of BDNF mRNA.

Example 7 Effect of Clomipramine on Nicotine-Induced Hypothermia in Rats

Following a similar protocol to that of Example 3, nicotine (2 mg/kg)alone or in combination with clomipramine (30 mg/kg) was injected torats 3 times, 2 h apart. The body temperature (0 C) was measured 30 minpost injection. FIG. 7 depicts the maximum decrease in body temperatureafter each injection. As can be seen, when nicotine was injected alone,a gradual decrease in the hypothermic effect was seen, indicating nAChRdesensitization. Clomipramine inhibited to some extent the effect ofnicotine in the first injection, but no further reduction in thehypothermic effect of nicotine was noted in consecutive injections,suggesting that clomipramine inhibits nAChR desensitization.

Example 8 Effect of Lidocaine on Nicotine-Induced Hypothermia in Rats

The experimental design was similar to that described in Example 3.Nicotine (2 mg/kg), lidocaine (15 mg/kg), and nicotine+lidocaine (2mg/kg+15 mg/kg) were administered to rats 2× day for two days, followingthe above protocol. FIGS. 8A-8B depicts the results on day 1 and day 2,respectively, indicating that lidocaine maintained the hypothermiceffect of nicotine compared to the loss of the hypothermic effect ofnicotine when it was given alone. These results show that lidocaineinhibits nAChR desensitization.

1. A method for treatment of a central nervous system (CNS) or aperipheral nervous system disorder, treating anxiety or depression,and/or treating or suppressing tobacco or nicotine dependence or usage,comprising co-administering to a patient in need thereof atherapeutically effective amount of a nicotinic agonist and a nicotinicacetylcholine receptor (nAChR) desensitization inhibitor.
 2. The methodof claim 1, wherein said CNS disorder is a cognitive disorder.
 3. Themethod of claim 2, wherein said CNS disorder is selected from the groupconsisting of Alzheimer's disease, Parkinson's disease, schizophrenia,attention deficit hyperactivity disorder (ADHD), attention deficitdisorder (ADD), vascular dementia, Lewy body disease, post-traumaticdementia, Pick's disease, multiple sclerosis, Jakob-Creutzfeldt disease,nicotine addiction, alcohol addiction, cannabis addiction, cocaineaddiction, neurological conditions associated with acquired immunedeficiency syndrome (AIDS), and Huntington's disease. 4.-5. (canceled)6. The method of claim 1 wherein the effect of a subsequentadministration of the nicotinic agonist to said patient is substantiallymore therapeutically effective as compared to a subsequentadministration of a nicotinic agonist using a method for treatmentconsisting of first administering to said patient a nicotinic agonistalone.
 7. (canceled)
 8. The method of claim 1, wherein the effect ofnicotinic agonist after co-administration is about twice as effective ascompared to administering to the patient the nicotinic agonist alone. 9.(canceled)
 10. The method of claim 1, wherein the nAChR desensitizationinhibitor reduces the desensitization of said nicotinic agonist for atleast about 12 hours. 11.-12. (canceled)
 13. The method of claim 1,wherein the nicotinic agonist and the nAChR desensitization inhibitorare administered together in the same dosage form.
 14. The method ofclaim 1, wherein the nicotinic agonist and the nAChR desensitizationinhibitor are administered in separate dosage forms. 15.-18. (canceled)19. The method of claim 1, wherein said nicotinic agonist and said nAChRdesensitization inhibitor are co-administered in the form of chewinggum, sachets, thin film, transdermal patches, capsules, tablets,lozenges, or nasal sprays.
 20. The method of claim 1, wherein thenicotinic agonist is administered transdermally.
 21. The method of claim1, wherein the nAChR desensitization inhibitor is administered orally.22.-25. (canceled)
 26. The method of claim 1, wherein said nicotinicagonist and said nAChR desensitization inhibitor are administered in onetransdermal patch. 27.-29. (canceled)
 30. The method of claim 1, whereinthe nicotinic agonist is chosen from: nicotine, decamethonium bromide,epibatidine, lobeline, varenicline, epiboxidine, epiquinamide, ABT-418,ABT-594, DMXB-A, altinicline and metanicotine, and combinations thereof.31. The method of claim 1, wherein the nicotinic agonist is nicotine ora pharmaceutically acceptable salt or N-oxide thereof.
 32. (canceled)33. The method of claim 1, wherein the nAChR desensitization inhibitoris chosen from: opipramol, galantamine, clomipramine, mirtazapine,maprotiline and lidocaine, and pharmaceutically acceptable salts,esters, and prodrugs thereof.
 34. The method of claim 1, wherein thenicotinic agonist is nicotine and the nAChR densitization inhibitor isopipramol or a pharmaceutically acceptable salt or ester thereof. 35.The method of claim 34, wherein about 5 mg/day to about 21 mg/day of thenicotine is administered.
 36. The method of claim 34, wherein about 50mg/day to about 250 mg/day of opipramol is administered. 37.-41.(canceled)
 42. A pharmaceutical composition comprising a nicotinicagonist and a nAChR desensitization inhibitor.
 43. The pharmaceuticalcomposition of claim 42, wherein the nicotinic agonist is chosen from:nicotine, decamethonium bromide, epibatidine, lobeline, varenicline,epiboxidine, epiquinamide, ABT-418, ABT-594, DMXB-A, altinicline andmetanicotine, and combinations or N-oxides thereof.
 44. Thepharmaceutical composition of claim 43, wherein the nicotinic agonist isnicotine.
 45. The pharmaceutical composition of claim 42, wherein thenAChR desensitization inhibitor is chosen from opipramol, galantamine,and lidocaine, and pharmaceutically acceptable salts, esters, andprodrugs thereof.
 46. The pharmaceutical composition of claim 42,wherein the nAChR desensitization inhibitor is opipramol, or apharmaceutically acceptable salt, ester, or prodrug thereof.
 47. Thepharmaceutical composition of claim 42, wherein the nicotinic agonistand nAChR desensitization inhibitor is present in a weight ratio ofnicotinic agonist:nAChR desensitization inhibitor of about 1:2 to about1:100.
 48. The pharmaceutical composition of claim 42, wherein thenicotinic agonist and nAChR desensitization inhibitor is present in aweight ratio of nicotinic agonist:nAChR desensitization inhibitor ofabout 1:5 to about 1:20.
 49. The pharmaceutical composition of claim 42,wherein the nicotinic agonist and nAChR desensitization inhibitor ispresent in a weight ratio of nicotinic agonist:nAChR desensitizationinhibitor of about 1:14.
 50. The pharmaceutical composition of claim 42,further comprising a pharmaceutically acceptable carrier.
 51. Thepharmaceutical composition of claim 50, wherein the pharmaceuticallyacceptable carrier is suitable for transdermal or topical administrationto a patient.
 52. The pharmaceutical composition of claim 42,comprising: a) nicotine or pharmaceutically acceptable salts or N-oxidesthereof, and b) opipramol or pharmaceutically acceptable salts, esters,and prodrugs thereof.
 53. The pharmaceutical composition of claim 42,wherein the amounts of each of nicotinic agonist and the nAchRdesensitization inhibitor are such that the combination provides aneffective amount of nicotinic agonist for the treatment of a centralnervous system disorder upon administration after one or more doses areadministered to a patient. 54.-55. (canceled)
 56. A transdermal patchcomprising the pharmaceutical composition of claim 42
 57. A transdermalpatch for administration of a co-therapy to a patient, wherein saidpatch comprises a) nicotine, b) opipramol or pharmaceutically acceptablesalts, esters, and prodrugs thereof, and c) a pharmaceuticallyacceptable carrier suitable for transdermal or topical administration toa patient.
 58. The transdermal patch of claim 57, wherein the patch isformulated to provide substantially continuous delivery of the nicotineand the opipramol to a patient.
 59. A method of treating Parkinson'sdisease, comprising administering to a patient in need thereof thetransdermal patch of claim
 57. 60. A method of treating Alzheimer'sdisease, comprising administering to a patient in need thereof thetransdermal patch of claim
 57. 61.-66. (canceled)